How Lifestyle Medicine Can Make a Difference in the Efficacy of Otolaryngologic Therapies

Something changed recently in my otolaryngology clinic. I’m board certified in both otolaryngology and lifestyle medicine, and this has prompted the change that has benefitted my patients and transformed my practice.

Before I became interested in a more holistic approach to otolaryngology, I had little to offer my patients in the way of medical advice other than reassurance that the “lump” sensation they were feeling wasn’t cancer but instead globus, and a prescription for nasal spray. 

But now, I find myself encouraging patients during their appointments to tell me more about the activity levels in their life, their nutritional habits, or the recent stress they’ve been under. Examining their timelines a little more closely has highlighted potential links between globus and a stressful life event, snoring and alcohol consumption, and sinus infections and a change in their workplace.

These in-depth discussions guide the patient to a better understanding of the problem and allow contemplation of a greater variety of treatment options. 

The Six Pillars of Lifestyle Medicine

The American College of Lifestyle Medicine (ACLM) was founded in 2004 to advance evidence-based lifestyle medicine to treat, reverse, and prevent noncommunicable chronic disease. Its membership has grown exponentially in the past few years and includes primary care and specialty physicians as well as a host of other healthcare professionals who are united in their desire to transform healthcare. Much of its research focuses heavily on cardiovascular disease, diabetes mellitus, stroke, and cancer. As otolaryngologists, we know these conditions impact our patients both directly and indirectly.

Lifestyle medicine focuses on six different areas, called pillars, to help improve overall health through modifiable lifestyle habits, and the medical literature supports the importance of these practices.

Pillar 1: Nutrition

More than 75% of U.S. adults do not get the recommended daily servings of fruits and vegetables, and over 60% of food consumed in the United States is processed. Plants contain fiber that helps regulate insulin sensitivity, vitamins and minerals that act as cofactors for biochemical pathways, and antioxidants that help reduce cellular damage. Robust data show that the whole-food plant-based strategy promoted by the ACLM supports health and longevity, and emerging research continues to shine a light on common otolaryngology complaints.

Much of [lifestyle medicine] research focuses heavily on cardiovascular disease, diabetes mellitus, stroke, and cancer. As otolaryngologists, we know these conditions impact our patients both directly and indirectly. —Jessica G. Lee, MD

Numerous studies show, for example, that increasing fruit, vegetable, and nut consumption can reduce rhino-conjunctivitis symptoms and wheezing (Allergol Immunopathol (Madr.) 2017;45:417-424; Thorax. 2007;62:677- 683; Public Health Nutr. 2006;9:472-479; Nutrients. 2021;13:728). A recent article in the April 2022 issue of the American Academy of Otolaryngology–Head and Neck Surgery’s Bulletin magazine succinctly compiled the evidence for protective effects of plant-based diets (AAO-HNS Bulletin. 2022;41:32-35). The preventative power of antioxidants has been demonstrated in animal models and smaller patient cohorts (Antioxidants. 2020;9:1076-1097; Ear & Hearing. 2019;41:289-299; Prasad KN, et al. The Case for Using Multiple Antioxidants in Hearing Disorders. The Hearing Review. Accessed June 6, 2008).

Dietary patterns that damage microvasculature are likely to impact the delicate inner ear microvasculature in a way that’s similar to retinopathy (JAMA Otolaryngol Head Neck Surg. 2020;146:152-159). Foremost recommendations for treating laryngopharyngeal reflux rely heavily on dietary modifications (JAMA Otolaryngol Head Neck Surg. 2017;142:1023-1029; Laryngoscope. 2022;132:1916-1923; Am J Otolaryngol Head Neck Med and Surg. 2018;39:50-55). Large observational studies also suggest the protective role of fruits and vegetables in upper aerodigestive cancer risk reduction (Int J Cancer. 2009;124:2671-2676).

Pillar 2: Physical Activity

A review of the benefits of physical activity turns up repeated studies that show that any amount of physical activity is beneficial, with optimal health benefits achieved at 150 minutes per week of moderate activity (CMAJ. 2006;174:801-809). Sedentary behavior has been linked to an increase in all-cause mortality, cardiovascular disease, diabetes, and Alzheimer’s disease (Korean J Fam Med. 2020;41:365-373).

In the latter half of our lives, sedentary behavior is likely responsible for the disequilibrium many of our patients describe, and treatment focuses on increasing movement and adding strength training and balance exercises. There is also evidence that physical activity improves allergy and asthma symptoms, decreases rates of cancer recurrence, and improves sleep quality (J. Clin. Med. 2020;9:706; Front. Aging. 2022;3:852643; Eur J Epidemiol. 2011;26:619-628; J Behav Med. 2015;38:427-449; Sleep Med. Rev. 2018;39:52-68).

Pillar 3: Sleep

An underappreciated health contributor is adequate, high-quality sleep. The American Academy of Sleep guidelines encourage seven to eight hours nightly, but in our fast-paced world many people boast about being able to function on much less than that. The restoration that occurs while we sleep is irreplaceable—even the best nutrition and exercise routine cannot overcome its absence.

Obstructive sleep apnea is something we tend to feel very comfortable discussing and treating, but how much do we discuss insomnia or “social jet lag” (defined as the delay in the natural sleep cycle of the body that happens when you stay up late on Friday and Saturday to socialize and then sleep in the next morning to catch up—and why so many of us feel tired on Monday morning)? Many patients treat their insomnia with pills as a first-line treatment when sleep hygiene, daily outdoor activity, and cognitive behavioral therapy are better recommended.

Pillar 4: Stress Management

An estimated 70% of primary care visits are related to stress in its various manifestations (Health Policy Q. 1981;1:159- 175). In a field of headaches, neck pain, dysphagia, and increased susceptibility to recurrent respiratory infections, I would suggest that the numbers for our patients are similar.

Using conversational skills to ask open-ended questions, allowing the patient time to reflect, and discussing how a life event may be affecting their health is critical as a primary modality of treating the patient’s symptoms and the distress caused by those symptoms. One of my favorite studies showed that patient-perceived provider empathy is associated with reduced cold severity and duration, with reduction in objective inflammatory markers (Patient Educ Couns. 2011;85:390-397). Abdominal breathing can improve gastroesophageal reflux disease symptoms (Am J Gastroenterol. 2012;107:372- 378), time in nature can improve sleep (Int J Environ Res Public Health. 2021;18:12426), and meditation can reduce susceptibility to colds (PLoS ONE. 2018;13:e0197778). All are easy, cost-effective strategies to help patients reduce stress and improve their health.

Pillar 5: Emotional and Mental Health

It’s wise to consider the emotional distress a new symptom can elicit, and the value in the relief of that distress. Patients with tinnitus and globus will often admit they just want to make sure it isn’t “something terrible.” Interestingly, a recent study looked at SinoNasal Outcome Test (SNOT-22) emotional and sleep domain scores and found sensitivities that were well over 80% for anxiety and depression screening (Otolaryngol Head Neck Surg. 2022;166:985-992).

This anxiety can affect patient outcomes post-treatment. Patients with a history of anxiety or depression may experience worse outcomes after surgery, for example (Ann Surgery. 2021;1:e049). Keeping emotional health in view expands our opportunities to improve our patients’ well-being. Fostering connections by setting up a small group of cancer survivors who volunteer as peer mentors, for example, is rewarding for the patient, the mentor, and you as their provider.

Pillar 6: Avoidance of Risky Substance Use

Most physicians mention quitting when patients report that they smoke, maybe even going on to explain the risk of cancer, but it’s worth acknowledging that tobacco dependence is a chronic illness and most people who are addicted will go through several attempts to quit before they find success, if they don’t give up on getting free of the addiction.

Instead, help motivate patients by teaching them that, according to the American Lung Association, after abstinence from smoking, their blood pressure will improve in 20 minutes, their breathing will improve in two months, and their risk of heart disease will be cut in half after one year. Becoming well versed on the methods of quitting is also useful for patients who don’t have a primary care doctor.

For some patients, there are moral implications of alcohol use, so it’s easy for a patient to feel defensive when a physician asks about their habits. Preface any discussions with a disclaimer (“This is a judgement-free zone!”) and explain that alcohol may be directly related to their symptoms. After calmly recording their response, inform them that even moderate drinking (more than seven drinks per week for women and more than 14 drinks per week for men) can have adverse health effects (Addict Health. 2019;11:129-137)—not to mention relationship effects (the weekend couch sleepers after a day of heavy drinking). Have a laugh about it together and then get back to business. Encouraging a break from alcohol of even just two weeks can illuminate its negative effects on sleep and improve postoperative wound healing. Many patients will settle back into a lighter consumption routine after the break.

Clinical Implementation

Lifestyle medicine trains providers to facilitate changes using the theories behind it, such as the Health Belief Model (developed in the early 1950s by social scientists at the U.S. Public Health Service that suggests that a patient’s belief in the threat of an illness and in the effectiveness of the recommended health behavior will predict the likelihood that the patient will adopt the behavior) and the Transtheoretical Model of Change (developed in the late 1970s and also called the Stages of Change Model, it assumes that patients don’t change habitual behaviors quickly and decisively but instead through a cyclical process).

Learning how to motivate patients by determining what their values and goals are leads to better compliance with treatment recommendations, whether it’s a lifestyle change, a new medication, or postoperative care. Current noncompliance rates for medication use are over 50%, with lack of motivation given as the top cause (Perm J. 2018;22:18-33). Using the basics of cognitive behavioral therapy and positive psychology, physicians can support and extend a patient’s health behavior self-efficacy.

The expansion of knowledge, the renewed passion, and the rewards of building deeper relationships with patients brings a much-needed healing tincture for physician wellness. According to a recent Medscape report, burnout rates among physicians are at an all-time high, with nearly 50% of physicians feeling dissatisfied. Coming together holistically with our patients strengthens the bonds of trust and encourages a more meaningful connection, which is the key to longevity and wellness (PLoS Med. 2010;7:e1000316). In the continuous pursuit of well-being, educating ourselves and our patients on the benefits of healthy lifestyle practices will allow us to reap the future rewards together.

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Dr. Lee is an otolaryngologist practicing at Charleston ENT & Allergy in S.C. and is board certified in otolaryngology and lifestyle medicine.